**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification survey from 10/26/2023 to 11/2/2023, the facility did not ensure accuracy of resident assessments. This was evident for 2 (Resident #100 and #170) of 36 total sampled residents. Specifically, 1) Resident #100's Minimum Data Set 3.0 (MDS) assessment did not document the resident's diagnosis of schizophrenia and depression, and 2) the Minimum Data Set 3.0 (MDS) assessment for Resident #170 documented the resident's planned discharge as an unplanned discharge. The findings are: The facility policy titled Resident Assessment Using the MDS dated [DATE] documented the facility will conduct initially and periodically a comprehensive and accurate assessment of each resident's functional capacity. 1) Resident #100 had diagnoses of schizophrenia and major depressive disorder. The MDS dated [DATE] documented Resident #100 was cognitively intact and diagnosed with depression and schizophrenia. The MDS dated [DATE] documented Resident #100 was cognitively intact and did not document Resident #100 was diagnosed with schizophrenia and depression. A comprehensive care plan (CCP) related to behavior initiated 6/13/2019 documented Resident #100 had a diagnosis of schizophrenia. A Psychiatry Note dated 8/22/2023 documented Resident #100 had diagnoses of schizophrenia and depression. An interview was conducted with the MDS Coordinator on 10/30/2023 at 11:47 AM who stated they look at the psychiatry notes to complete the diagnosis section of the MDS. Psychiatry did not document Resident #100's diagnosis of schizophrenia and only documented a history of schizophrenia so the MDS Coordinator did not document schizophrenia on the 9/25/2023 MDS for Resident #100. An interview was conducted with the Director of Nursing (DNS) on 10/30/2023 at 12:14 PM who stated the MDS Coordinator was responsible for filling out the diagnosis section on the MDS. The diagnoses were obtained from the resident's hospital discharge paperwork, physician orders, and progress notes. The DNS was unable to explain the reason Resident #100's 9/25/2023 MDS did not include the diagnosis of schizophrenia or depression. An interview was conducted with the Psychiatrist on 10/31/2023 at 3:10 PM who stated Resident #100 had a diagnosis of schizophrenia according to their documentation in the medical record. 2) Resident #170 had diagnoses of 2nd and 3rd degree burns and anxiety disorder. The MDS dated [DATE] documented Resident #170 had an unplanned discharge and return was not anticipated. The Comprehensive Care Plan (CCP) related to discharge planning initiated 2/23/2023 documented Resident #170 would be safely discharged to the community. A Physician Note dated 8/25/2023 documented Resident #170 was in optimal medical condition and was being discharged home with home care and walker. A Social Work Note dated 08/27/2023 documented Resident #170 was scheduled for discharge home on 8/31/2023. A Nursing Note dated 08/31/2023 documented Resident #170 was discharged home with medications, prescriptions, and belongings. On 10/31/2023 at 02:48 PM, the MDS Coordinator was interviewed and stated they were responsible for completing the discharge MDS assessment for Resident #170 on 8/31/2023. Unplanned discharge was triggered in error and planned discharge should have been triggered on the MDS assessment instead. 10 NYCRR 415.11(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the recertification survey from 10/26/2023 to 11/2/2023, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice. This was evident for 1 (Resident #121) of 9 residents reviewed for accidents out of 36 total sampled residents. Specifically, Resident #121 was observed without a soft helmet in place when out of bed in accordance with Physician's Order (PO). The findings are: A facility policy titled Adaptive Equipment dated 1/2/2021 documented the nursing department and the rehabilitation department will monitor care and proper use of the adaptive device. Nursing will document the use of these devices on the Certified Nursing Assistant (CNA) accountability record. Resident #121 was diagnosed with vascular dementia and schizophrenia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #121 was severely cognitively impaired and required extensive to total assistance to perform activities of daily living. On 10/26/2023 at 12:16 PM, 10/31/2023 at 11:25 AM, and 10/31/2023 at 11:55 AM, Resident #121 was observed out of bed to a recliner without a soft helmet in place. The soft helmet was observed on the resident's bedside table. The PO dated 12/18/2020 documented Resident #121 wear a soft helmet when out of bed for safety. The CNA Instructions for 10/2023 documented Resident #121 wore a helmet when out of bed for safety. On 10/31/2023 at 11:56 AM, CNA #1 was interviewed and stated they look at the CNA instructions to determine resident care needs. CNA #1 was not aware of any safety instructions for Resident #121. When CNA #1 was referred to the helmet on Resident #121's bedside table, CNA #1 stated the helmet is too big for the resident's head, they are not the regular CNA for Resident #121, and they did not report to anyone that the helmet was too big for the resident. On 10/31/2023 at 12:01 PM, Licensed Practical Nurse (LPN) #1, was interviewed and stated they were unaware the helmet for Resident #121 was too big. LPN #1 performs rounds and talks with the residents to ensure CNAs are performing their daily tasks. LPN #1 stated they saw Resident #121 without the helmet in place and did not address it with the resident's assigned CNA. 10 NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during a Recertification survey, the facility did not ensure residents' rooms were maintained in a homelike environment. Specifically, five rooms on the second and one room on the third floor were noted with air conditioning (AC) units with gray colored dust buildup in the filters and brown/black spots on the grates. This was evident for 2 out of 5 floors observed for the Environment. The findings are: The facility did not have a policy and procedure related to maintaining resident AC units. On 09/15/2021 at 02:34 PM and 09/21/2021 at 2:26PM, the AC unit in room [ROOM NUMBER] was observed with gray dust buildup on the filter and black spots on 8 vent grates that the air conditioning flows through to enter the resident's room. The ledge under the AC unit was also covered in gray dust. On 09/16/2021 at 08:29 AM and 09/21/2021 at 02:17 PM, the AC unit in room [ROOM NUMBER] was observed with gray dust buildup on the filter, and dust and black spots on 12 out of 12 vent grates. On 09/16/2021 at 10:09 AM and 09/20/2021 at 06:03 PM, the AC unit in room [ROOM NUMBER] was observed to have a broken plastic cover that was missing a piece large enough to expose the filter. The filter was covered in gray dust. There were black spots on 12 of 12 vent grates and dust on 7 of 12 vent grates. On 09/16/2021 at 11:07AM and 09/21/2021 at 02:22PM, the AC unit in room [ROOM NUMBER]A was observed with gray dust covering the vent grate. On 09/20/2021 at 12:48 PM, the AC unit in room [ROOM NUMBER] was observed with gray colored dirt and dust on 14 of 14 grates and black spots on the plastic cover. On 09/20/2021 at 06:01 PM and 09/21/2021 at 02:20PM, the AC unit in room [ROOM NUMBER] was observed with gray dust and black spots covering the vent grates, and gray dust covering the plastic cover. The Park Nursing Home Maintenance Department Semi Annual A/C Filter log dated 07/07/2021 documented that the AC filters were not replaced for room [ROOM NUMBER] to 235 and room [ROOM NUMBER] to 335 and the filter for room [ROOM NUMBER] was replaced due to be noted to be broken. An interview was conducted with Certified Nursing Assistant (CNA ) #1 (on 2nd Floor) on 09/21/2021 at 02:34PM. CNA #1 stated dust has been observed on the AC units but Maintenance us responsible for cleaning the filters. On 09/21/2021 at 2:48PM, an interview was conducted with Licensed Practical Nurse (LPN) # 3 (on the 2nd Floor) who stated it is not the responsibility of the LPN to check the AC units unless they need repair. The staff can either call Maintenance or write concerns in the Maintenance Book. On 09/21/2021 at 02:50PM, CNA #9 (on the 2nd Floor) was interviewed and stated when the AC units are dirty, the CNA reports it to their supervisor or writes it in the Maintenance Book. CNA #9 would observe whether the AC units are dirty when it is hot and they are turning the units on. On 09/21/2021 at 2:54PM, an interview was conducted with Housekeeper (HK # 1) who stated Housekeeping is responsible for cleaning the removable parts of the AC units with bleach and sanitizing wipes. Maintenance is responsible for changing the filter. On 09/21/2021 at 02:59PM, LPN #4 from the 2nd Floor was interviewed and stated LPNs conduct morning rounds and sometimes look at the AC unit. Maintenance is responsible for taking care of it. LPN #4 observed and was aware of the dusty AC units in room [ROOM NUMBER] and room [ROOM NUMBER], but did not report it. On 09/21/2021 at 03:03PM, HK #2 was interviewed and stated the Housekeeper is responsible for observing the AC units and informing Maintenance if the filter or vents need to be cleaned or if there is a functional concern. HK #2 will sometimes clean the unit by wiping down the vent grates and the outside of the unit. After observing room [ROOM NUMBER] and room [ROOM NUMBER], HK #2 stated the vents are dirty and need to be cleaned. On 09/21/2021 at 03:33PM, the Maintenance Worker (MW #1) was interviewed, and stated Maintenance is responsible for cleaning the AC unit filters and report any broke to their supervisor. The filters on all AC units were last cleaned in July 2021. The Maintenance department check the filters every 1-2 months and if dirty. MW #1 turned on the AC unit in room [ROOM NUMBER] and dust was observed flying from the unit into the air. MW #1 stated the filter for the AC in room [ROOM NUMBER] was cleaned in July and Maintenance is not responsible for dusty vent grates. On 09/21/2021 at 04:36PM, the Director of Housekeeping (DH) was interviewed, and stated Housekeeping is responsible for cleaning the exterior of the AC unit. The DH conducts daily rounds of resident rooms. The AC filters are cleaned by Maintenance and Housekeeping is responsible for the external parts of the AC unit. On 09/21/2021 at 4:07PM, the Director of Maintenance (DOM) was interviewed. DOM stated rounds are done weekly to check if AC unit filters need to be cleaned. Most filters were last cleaned July 2021. The filters may get dirty more often because the facility is located by the water. Maintenance staff clean AC unit filters quarterly, as needed, and per manufacturer recommendations. There is no policy and procedure on cleaning AC units. 415.12(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the Recertification survey conducted from 9/15/21 to 9/22/21, the facility did not ensure that a resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene. Specifically, a resident was observed on more than one occasion over 6 days to have fingernails approximately quarter inch from the tip of the fingers. This was evident for 1 of 3 residents reviewed for Activities of Daily Living out of a sample of 40 residents. (Resident # 324). The finding is: The facility Policy & Procedure titled Resident Hygiene and Daily Care with effective date 05/21/2021 documented Residents will be provided with or assisted with daily hygiene and care in-order to promote dignity and wellness. It also documented The Nursing Assistant will provide nail care as needed on shower days to ensure that nails are clean, smooth, and trimmed. Resident # 324 was admitted to the facility on [DATE] with diagnoses that included Secondary Parkinsonism Unspecified, Other Depressive Episodes, and Parkinson's Disease. The admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #324 had intact cognition and no rejection of care behavior. It also documented Resident # 324 required extensive assistance of 2 persons for bed mobility and transfer, limited assistance with 1 person physical assist for eating, extensive assistance with 1 person for personal hygiene, and was totally dependent with 2 persons assist for toilet use. On 09/15/21 at 03:02 PM, an interview was conducted with Resident # 324. Resident #324 was observed with fingernails on both hands extending a quarter inch in length from the tip of the fingers. Resident #324 stated their fingernails had not been cut for 3 months. Resident # 324 also stated they wanted their fingernails to be trimmed once every 1 to 2 weeks. Resident #324 further stated they required staff assistance with trimming the fingernails. On 09/17/21 at 10:55 AM, Resident # 324 was observed sitting in a wheelchair in the room. Resident # 324's fingernails were un-trimmed and a quarter inch in length. On 09/20/21 at 11:17 AM, Resident #324 was observed wheeling themselves in the wheelchair by the nursing station. Resident #324's fingernails were still a quarter inch in length. The Comprehensive Care Plan for ADLs Activity of Daily Living with effective date on 5/19/2020 and last update on 9/11/2021 documented resident required extensive assistance with 1 person physical assist for personal hygiene and grooming, and limited assistance with 1 person physical assist for bathing. The goal was Resident will continue to function at current level daily x 90 days with review date 12/07/2021. Interventions included Allow resident to participate in decision making and Anticipate needs. The Certified Nursing Assistant (CNA) Accountability Record dated from 8/31/2021 to 9/20/2021 revealed there was no documentation recorded on the specific grooming that had been provided to the resident. On 09/21/21 at 09:42 AM, an interview was conducted with the Certified Nursing Assistant (CNA) #5. CNA #5 stated they provided care to Resident #324 from 8/31/2021 to 9/19/2021. CNA #5 stated Resident #324 required extensive assistance with 1 person for ADLs. CNA # 5 also stated Resident #324 did not refuse care. CNA # 5 stated they thought the fingernails were long when they grew beyond the fingertips, and it was the responsibility of CNA to trim the fingernails when they were long. CNA # 5 stated they did not observe that Resident # 324 had long fingernails. CNA # 5 also stated cutting and trimming of fingernails was discussed in the orientation and in-services. On 09/20/21 at 12:23 PM, an interview was conducted with the Certified Nursing Assistant (CNA) # 4. CNA #4 stated they were assigned to Resident #324 starting today, and the resident received total care. CNA #4 stated they trim the fingernails of non-diabetic residents after the AM care if the fingernails are long, and Resident #324 is not Diabetic. CNA # 4 also stated Resident #324 did not refuse care. CNA # 4 stated during orientation and in-services throughout the year, their tasks like dressing the resident appropriately, cutting and trimming of fingernails are discussed. CNA # 4 was not sure why Resident # 324's fingernails were not trimmed. On 09/20/21 at 05:58 PM, an interview was conducted with the Assistant Director of Nursing (ADN). The ADN stated the Certified Nursing Assistant (CNA) could trim the fingernails for non-diabetic residents and should trim the fingernails when they saw the fingernails were long. The ADN considered the fingernails long when they grew beyond the fingertips. The ADN further stated the CNAs were instructed that their tasks included checking and trimming the fingernails if they were long or to notify the nurses during the CNA orientation and in-services afterward. The ADN stated there was no column in the Electronic Medical Record (EMR) where the CNA could document that nail trimming was provided to the residents. The ADN does rounds in the unit several times a day to monitor the staff and spot check the residents. The ADN assessed the fingernails of Resident # 324 and stated they were not aware Resident # 324 had these long fingernails. The ADN also stated Resident # 324's fingernails were a quarter inch long and the CNA should trim these fingernails. 415.12(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview during the Recertification survey conducted from 9/15/21 to 9/22/21, the facility did not ensure an ongoing program of activities was provided to meet the interests of and support the physical, mental, and psychosocial well-being of the resident based on the comprehensive assessment and care plan. Specifically, a resident with major depressive disorder was observed for extended periods of time without meaningful activities. This was evident for 1 of 2 residents reviewed for Activities out of 40 sampled residents (Resident # 46). The finding is: The facility Policy and Procedure tilted General Recreation Policies with effective date 6/2017 and no last review date documented it is the policy of this facility that an ongoing program of Recreation Department, as part of the Multidisciplinary Care Team, provides comprehensive and diversified leisure programming geared to the enhancement of the social, emotional, intellectual, physical, creative and spiritual well-being of our resident population, seven days per week, in accordance with psychosocial assessment of the resident. It also documented Recreation services, inclusive of assessment, counseling and programming, are provided to all residents in the facility. This includes the Long-Term Care population as well as the Short-Term Care patients. Specially tailored programs are designed to meet individual needs of all resident populations. Resident #46 was admitted to the facility on [DATE] with diagnoses that included Major depressive disorder, Generalized anxiety disorder, and Bipolar disorder. The significant change Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #46 had moderately impaired cognition (Brief Interview of Mental Status score 8 out of 15) and did not reject care. The MDS documented the resident's activity preferences included: Family or significant other involvement in care discussions, Reading books, newspapers, or magazines, Listening to music, and Doing things with groups of people. The MDS also documented resident required limited assistance with 1 person assist for bed mobility, extensive assistance with 1 person for transfer and toilet use, and supervision with setup for eating. On 09/15/21 at 02:18 PM, Resident #46 was interviewed and stated they had no preferred activity to participate in the facility. Resident #46 also stated they went down to the activity room on first floor for some activities like Bingo or Ice-cream sometimes and had not been outdoor for long time. Resident #46 further stated they liked to listen to music, watch TV, read newspaper and magazines, play cards with other residents, and have some outdoor activities. Resident # 46 was observed sitting in the Geri chair or wheelchair and lying in bed for several days at various times during the recertification period in their room and by nursing station. On 09/17/21 at 10:48 AM, Resident # 46 was observed sitting in a Geri chair and had no ongoing activity in the room. On 09/17/21 at 11:13 AM, Resident # 46 was observed sitting in the wheelchair by the nursing station without ongoing activity. On 09/17/21 from 03:27 PM to 04:30 PM, Resident # 46 was observed sitting in a wheelchair across the nursing station with no ongoing activity and falling asleep. On 09/20/21 at 09:04 AM, Resident # 46 was observed sleeping in bed. On 09/20/21 at 11:25 AM, Resident # 46 was observed lying in bed and had no ongoing activity in the room. On 09/20/21 at 03:33 PM, Resident # 46 was observed sitting in a wheelchair across the nursing station and had no ongoing activity. On 09/20/21 at 04:27 PM, Resident # 46 was observed sitting in the wheelchair at same place across the nursing station with no ongoing activity. On 09/21/21 at 03:23 PM, Resident # 46 was observed sitting in the wheelchair in the room and had no ongoing activity. On 09/22/21 at 09:36 AM, Resident # 46 was observed sitting in the wheelchair by nursing station and had no ongoing activity. The Comprehensive Care Plan for Active Participant with effective date 9/8/2021 documented Resident attends programming and is an active participant in leisure pursuits of choice. At times resident is passive. The goal was Resident will maintain current level of functioning evident by continual active participation during programs of interest x 3 months. The interventions included Encourage participation in structured and unstructured programs of interest, Provide invitation and assistance as needed to programs of interest and Provide resident with monthly activity calendar. The Activities - Initial/Comprehensive Assessment created on 6/18/2021 and completed on 6/25/2021 documented that Resident # 46's daily and activity preferences included reading books, newspaper, or magazines; listening to music; doing things with groups of people; and spending time outdoors. On 09/20/21 at 12:49 PM, Certified Nursing Assistant (CNA) # 3 was interviewed and stated they did not know Resident # 46 had any activity from the recreation department. CNA # 3 also stated there was limited activities on the unit. CNA # 3 further stated they knew Resident # 46 went down to the first floor to play Bingo sometimes. On 09/21/21 at 10:32 AM, the Recreation Director Assistant (RDA) was interviewed and stated there is a bulletin board on each floor showing the daily recreation activities available to all residents for the month. The RDA also stated all residents have an activity assessment for their preferences. The RDA stated Resident # 46 had an activity assessment on June 25, 2021, and it indicated Resident # 46's preferences included reading books, newspaper, or magazines; listening to music; doing things with groups of people; and spending time outdoors. The RDA also stated Resident # 46 had no preferred activities scheduled. The RDA further stated Resident # 46 could only participate in the activities listed on the bulletin board for all residents during the month. The RDA stated they were hiring more recreation staff and expected 2 more staff joining them in 1 to 2 weeks. The RDA also stated that they would order and provide materials, including reading materials, music, TV, etc., that resident preferred to do independently in room. The RDA further stated the group activities were organized on the first floor and all residents were provided with the activities schedule and welcome to join. The RDA stated the Recreation Director left the facility two weeks ago, the RDA currently oversees the Recreation Department. The RDA reports to the Administrator now. 415.5(f)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #122 Based on observations, record reviews and interviews conducted during the recertification survey, the facility did not ensure a resident with or without an indwelling catheter, receives the appropriate care and services to prevent urinary tract infections to the extent possible. Specifically, a resident with a Foley Catheter in place had no documented evidence that Foley Care was provided. This was evident of 1 out of 2 residents investigated for Urinary Catheter, out of an investigative sample of 40 residents, (Resident #122). The findings are: The facility's Policy and Procedure on Foley Catheter Care dated effective 10/19/2021 documented that catheter care is performed appropriately to prevent complications cause by the presence of Foley catheter. The policy further documented Care Plan should address care of the tube. The policy have no documented evidence that care will be provided and documented by Certified Nursing Assistance (CNA). Resident #122 was re-admitted to the facility on [DATE] with diagnosis which include Neurogenic Bladder, Septicemia, and Urinary Tract Infection (UTI) (LAST 30 DAYS), Alzheimer's Dementia. The Quarterly Minimum Data Set 3.0 (MDS) dated [DATE] documented the resident had severely impaired cognition, was never or rarely understood with short-term and Long-term memory problem. The MDS further documented the resident was totally dependent on two or more persons for most Activities of daily Living (ADL), had and indwelling catheter, and was always incontinent of bowel. On 09/17/21 at 08:46 AM, Resident #122 was observed lying in low bed in no distress. Hand roll in left hand appears sleeping. Foley Catheter observed on left side in privacy bag draining yellow urine into a drainage bag. On 09/20/21 at 12:12 PM, Resident #122 observed up out of bed sitting chair in the room listening to TV. Staff reported a leg bag in place. The Comprehensive Care Plan (CCP) titled Alteration in Urinary Elimination, Actual created on 2/8/2021 and reviewed on 9/17/2021 with interventions including encourage oral fluids/provide adequate fluids, observe skin for signs of redness. Provide dignity and privacy in management of incontinent episodes and Catheter care as ordered. A Urology note dated 7/26/2021 documented the resident was seen on 7/25/2021 with Foley Catheter. Medication reviewed. Physical examination: within normal limits, urine is clear, and bladder not distended. Labs: Reviewed. Impression: Benign Prostatic Hyperplasia (BPH). Plan: Proscar daily and Flomax daily. Remove Foley in about two weeks. A Medical progress note dated 8/17/2021 documented the resident was examined at bedside. The resident was status post urinary retention secondary to BPH. The Foley removal trial failed, will insert new Foley French16 in sterile condition, continues Cardura, Flomax, follow up with GU, care to Foley and change per facility protocol. Physician orders dated 9/1/2021 documented orders for Foley Catheter Cath size: 16 French Balloon size: 10 ml Diagnosis/ Reason: Neuromuscular Dysfunction of the bladder and Change Foley catheter every month on the 1st Friday by unit Registered nurse (RN). There were no orders for Foley Care. Nursing progress note dated 9/12/2021 documented Alert and verbally responsive, in no distress, Foley Catheter size 16 French patent and intact draining 650 cc of amber urine, low floor bed and Bilateral floor mats in place, safety maintained, will continue to monitor Review of Certified Nursing Assistant (CNA) Accountability dated April 2021 through September 18th, 2021 have no documented evidence that Foley care was provided. Review of Certified Nursing Assistant (CNA) Accountability dated April 2021 through September 18th, 2021 have no documented that CNA have instructions to provide Foley Care. Review of Nursing progress notes from 4/15/2021 to 9/12/2021 have no documented evidence that Foley care was rendered. There was no documented evidence that the care for the Foley catheter was provided. On 09/20/21 at 05:48 PM, an interview was conducted with Certified Nursing Assistant (CNA #2). CNA #2 stated Resident #122 required total assistance with Activities of Daily Living (ADL) and had a Foley catheter in place. The urine bag is emptied twice per shift and output reported to nurse at the end of th shift. Foley care is done with soap and water. CNA #2 reports to the nurse if there is any change in urine color, blood in urine, pain, or no output. CNA #2 always signs the accountability record that Foley care was given, but was unable to produce documented evidence that Foley care was provided on 9/19/2021. CNA #2 stated they did not know how to produce documented evidence of the last time Foley care was given. On 09/21/21 at 02:07 PM, an interview was conducted with CNA #1. CNA #1 stated Resident #122 required two-person assist and have a Foley catheter in place. CNA #1 cares for the Foley Catheter daily by ensuring the catheter is clean, the drainage bag with privacy bag is in place at bedtime, and a leg bag is placed during the day. They clean the area with a wash cloth, wet with soap and water. CNA #1 wipes the insertion point, cleans around the area, and dries the area when finished. CNA #1 reports any changes such as bleeding, change in color, no drainage or pain to the nurse. The drainage bag is emptied every day at 10:00AM and at 2:00pm, and and the amount is documented on the assignment paper for the nurse. The CNA documents the Foley care in the CNA Accountability. CNA #1 could not show any past documentation for Foley care. CNA #1 stated they did not know what happened. On 09/21/21 at 02:14 PM, an interview was conducted with License Practical Nurse (LPN#1) on the unit. LPN #1 stated provides Foley Care by cleaning around the penile area with normal saline every day and applying A& D ointment. LPN #1 stated the CNA empties the drainage and report to the Nurse the amount every shift by placing the output on the assignment sheet. LPN #1 stated then documented the amount in the nurse's progress notes, and stated the CNA also provides and document the care in in the CNA Accountability. LPN #1 was asked to show surveyor where the care was documented. LPN#1 logged into SIGMA but was unable to show surveyor any documentation for the CNA administering care. LPN#1 also stated gives care and added the CNA automatically provides all the care every day every day and every shift. LPN#1 unable to explain why the task for the Foley Care was not in the CNA Accountability care was not ordered, why the care was not documented, and had no explanation why LPN#1 did not document care provided. LPN added will inform the nursing supervisor for the unit. On 09/21/21 at 02:57 PM, an interview was conducted with Assistant Director of Nursing (ADNS). ADNS stated responsible for covering unit #1. Foley care is documented in the CNA Assignment. The CNA is responsible for giving Foley care and reports any changes to the nurse. The CNA should report if the Foley is out, changes in color, odor of the urine or pain in the area. The ADNS stated the Foley task was a part of the CNA Accountability, but the task was not triggered or activated for the CNA to sign for Resident #122, therefore despite the CNA giving the care, the CNA documentation was not registered. RNS/ADNS stated this was a mistake on the part of the Facility. The nurse is responsible for triggering the tasks for the CNA to sign-off upon completion. RNS also stated will in-service the entire house regarding triggering of task, and the CNAs will be in-serviced regarding reporting to the nurse if the task is not triggered. The RNS/ADNS added all initial orders are placed by the RN upon admission, and the missing Foley care order was an oversight. On 9/20/2021 at 2:45 PM, the Director of Nursing Services (DNS) was interviewed and stated as per the facility policy, Foley care is a CNA task, and the CNA assigned to the resident signs for the care. DNS attempted to provide an undated CNA Accountability for Resident #122 as proof that Foley Catheter Care was part of the medical record. After reviewing the document, DNS was unable to provide an explanation why the section Foley Catheter Care was Inactive marked with an x and unable to be signed for by the CNA. 415.12(d)(1)

Based on observations, record review, and interviews conducted during the Recertification survey, the facility did not ensure safe food handling and storage was practiced to prevent food-borne illness. Specifically, expired food was found stored in the kitchen freezer and the emergency food storage area. This was evident during the Kitchen Observation task. The findings are: The facility policy and procedure titled Receiving and Storage of Deliveries; Food and Non-Food Items dated 11/20/2019 documented all deliveries must be inspected for damage, rodent or insect infestation, spoilage and expiration dates. All items are to be rotated using the First-In First Out method. This requires the staff to place the newly delivered food item behind the same food item in the storage areas, the newly delivered item can be placed in front of the shelving unit. Staff assigned to putting away the delivery will be required to check expiration dates of current existing food items in designated areas. Any expired items must be removed and discarded. The policy Emergency Food Supply reviewed 11/17/2017 documented al items will be dated as to the date of delivery, non-puree items will be rotated every six months and all puree foods will be rotated a month prior to the manufacturers expiration date. On 09/15/2021 between 09:17 AM and 09:32 AM, an initial tour of the kitchen and facility's emergency food supply was done. Two cardboard boxes containing 6 individual 1-quart cartons of Lactaid milk and a total of 12- quart cartons were observed in the kitchen freezer with an expiration date of 09/10/2021. The Emergency Food Room located on the first floor was observed to contain the following expired food: one box of 8 packs of 4 ounce tubs of pureed sweet potato with expiration date 7/31/2021, four boxes of 8 packs of 4 oz tubs of pureed peas with expiration date 8/31/2021, and three boxes of 8 packs of 4 ounce tubs of peas, carrots. An interview was conducted with Relief [NAME] (DA #1) on 09/15/2021 at 09:39 AM. DA #1 stated they are responsible for putting the milk away upon delivery and sometimes places the milk in the freezer. DA #1 came in at 9AM this morning and does check expiration dates. The milk should be used before the expiration date. On 09/15/2021 at 09:51AM, the Food Service Supervisor (FSS) was interviewed and stated the FSS is responsible for checking dates every morning but has not checked the boxes of milk recently. The FSS does not use a checklist or have documented evidence of daily checks. The milk is normally used before the expiration date but Lactaid milk may be frozen if the facility received extra. The DA is responsible for rotating the boxes when they inventory milks for the FSS. On 09/17/2021 at 12:43PM, The Registered Dietitian (RD #1) was interviewed and stated they are responsible for monitoring the rotation of food items to ensure use by expiration date and prevent foodborne illness. RD #1 was unable to provide documented evidence of monitoring. On 09/17/2021 at 11:53 AM and 01:55 PM, the Corporate RD (RD #2) was interviewed, and stated emergency food supply is checked every 6 months so foods set to expire within 1-3 weeks are rotated out. These items are then replenished. The expired food items should have been thrown away. It was an oversite. 415.14 (h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) The facility undated policy titled Hand Hygiene documented hand hygiene is to be performed before and after patient care, whenever hands come into contact with the resident's environment. Alcohol-based hand sanitizer is to be used after touching a patient or the patients immediate environment, or immediately before touching a resident. On 09/15/2021 at 12:47 PM, Registered Nurse (RN) #1 was observed in the 2nd Floor Dining Room removing a bib from their pocket with bare hands and placing it on Resident #36. RN #1's hands touched the residents clothing when they assisted with placing the bib and adjusting it. RN #1 then placed a bib on Resident #78, opened a sugar packet, and poured the sugar into Resident #78's beverage cup. No hand hygiene was observed in between residents or before opening the sugar packet. RN #1 proceeded to open plastic utensil packet from Resident #78's tray placed the plastic spoon in their soup, picked up a 2nd spoon that dropped onto the resident's tray with bare hands, and placed the 2nd spoon in a fruit cup on the tray. On 09/15/2021 at 05:12 PM, RN #1 was interviewed and stated hand hygiene is done after assisting a resident. RN #1 did not think hand hygiene needed to be done in between each bib placement. Hand hygiene should have been done before touching the sugar packet. RN #1 stated the bibs were in their pocket and usually they don't put anything in their pocket. 3). On 09/16/2021 at 12:21PM, LPN #2 was observed in the 2nd Floor Dining Room assisting with lunch. LPN #2 assisted Resident # 92 with opening their 4 oz milk carton. LPN #2 touched the outside of their surgical mask and then picked up a knife from Resident #17's tray and asking if the resident needed help. Resident #17 declined and LPN #2 placed the knife back onto the resident's tray. LPN #2 then went to Resident #125 who was in a wheelchair near the entrance to the dining room. LPN #2 pushed the resident to their table, locked the wheelchair, wiped the resident's hand with a hand wipe, and placed the used hand wipe in the left pocket of their scrubs top. On 09/16/2021 at 12:40PM, LPN #2 was interviewed and stated hand and pump sanitizer are used for hand hygiene. Hand hygiene should be done before residents are served and before/after assisting a resident. They stated they must have been confused and used hand wipes only. On 09/21/2021 at 12:34PM, RN #2, who was present in the 2nd Floor Dining Room during dining observation, was interviewed and stated the before staff come they should perform hand hygiene, when visibly soiled and if not use hand sanitizer. We have hand sanitizer on the wall and can use for hand hygiene. If staff handle tray, touch food with bare hands we call to replace food. Hand hygiene should be done before and after providing assistance to a resident. They observe hand hygiene in the dining room and when rounding on the unit. 415.19(b)(4) Based on observations, record review, and staff interviews during the recertification survey, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, 1) oxygen tubing was observed on multiple occasions touching the floor; and, 2) staff were observed not performing hand hygiene during dining in between assisting residents. This was evident for 1 of 4 residents observed for Respiratory Care (Resident #155) and 1 out of 5 units observed for dining (Residents # 36, #78, #92 and #125) on unit # 2 out of an investigative sample of 40 residents. The findings are: 1.) Resident #155 had a diagnosis of Malignant Neoplasm of the Bladder, Chronic Obstructive Pulmonary Disease (COPD), Heart Disease and Dependence on Oxygen. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented resident was moderately impaired, required extensive to total assistance with Activities of Daily Living (ADL), and was receiving Oxygen Therapy. On 09/16/21 at 08:22 AM, 09/16/21 at 10:19 AM, 09/17/21 at 08:47 AM, 09/21/21 at 02:05 PM Resident #155 was observed lying in bed receiving oxygen via nasal cannula tubing in nostrils. The tubing was observed lying on the floor in between the resident and the oxygen concentrator it was attached to. On 09/22/2021 at 2:15 PM, resident observation conducted with License Practical Nurse (LPN#1) present. Oxygen tubing that was attached to the oxygen concentrator led to the resident's nostrils. LPN #1 was observed picking up the oxygen tubing from the floor and placing it on the resident's bed. LPN #1 did not sanitize of replace the oxygen tubing. The facility policy titled Oxygen Therapy dated effective 7/30/2021 documented when the use of longer tubing is necessary, clip and loop the longer tubing together and attach to resident bed. Oxygen tubing will be checked to ensure it is not touching the floor, when indicated excess tubing will be secure to prevent it from touching the floor, and oxygen tubing noted touching the floor will be cleaned with EPA registered germicidal wipes or replaced. Physician orders dated 9/13/2021 documented Resident #155 was to receive continuous oxygen @ 2 liters per minute via nasal cannula secondary to COPD. The Treatment Administration Record (TAR) dated 9/13/2021 documented resident received oxygen as ordered by the physician. On 09/21/21 at 02:19 PM, an interview was conducted with LPN#1 who stated they monitor all residents on oxygen during rounds and medication administration. Resident #155 is visually impaired and needs assistance from staff to ensure oxygen tubing is placed appropriately. LPN #1 did not see the oxygen tubing resting on the ground and will change it immediately. The Certified Nursing Assistant (CNA) will be reminded the oxygen tubing should not rest on the ground. On 09/21/21 at 03:02 PM, an interview was conducted with the Assistant Director of Nursing (ADNS) who stated all staff, especially nurses, are aware oxygen tubing should not be touching the floor. The resident was in a low bed which may have caused tubing to rest on the floor. Tubing can be kept off the floor by using a clip. The facility is responsible for finding a way to keep oxygen tubing off the ground. Morning and periodic rounds are done daily to monitor staff. If oxygen tubing is on the floor, it must be replaced immediately or cleaned with EPA wipes, and the tubing ADNS stated if the tubing is on the floor, it must be replaced immediately or cleaned with EPA wipes and adjusted so it stays off the floor.

Based on observation and staff interviews conducted during the Recertification survey, the facility did not ensure that the daily staffing was posted in a prominent place readily accessible to residents and visitors. Specifically, daily nursing staffing was not observed to be posted on 4 separate occasions. The findings are On 09/16/21 at 10:20 am, 09/17/21 at 10:20am, 9/20/21 at 10:05am, and 09/21/21 at 9:00am, observations of the facility areas accessible to residents and visitors were made. There were no observations that daily nursing staffing was posted. on the 1st floor there was no nursing staffing posted observed in a prominent place, accessible to residents and visitors On 09/21/21 at 1:55pm, an interview was conducted with the Director of Nursing (DON). The DON stated that she was aware of the daily staffing and that they usually post it and sometimes the residents may take it down. The DON then stated that the morning Supervisor is responsible for putting up the Staffing Postings. The DON further stated that she would call to have it posted since someone was working on it now, during the interview. 415.13

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews during the re-certification and abbreviated survey (NY#00227907) , the facility did not ensure other residents remained free from abuse. Specifically, a cognitively impaired resident who displays physical aggression towards others physically assaulted more than one resident, on more than one occasion. More specifically, interventions that were put in place to address this aggressive behavior were not evaluated for their effectiveness. This was evident in 1 out of 4 residents reviewed for resident to resident altercations and abuse care area (Resident #282). The finding is: The facility policy and procedure titled, Abuse Prevention (Dated 11/2018) documented the following: The facility policy is to provide a safe resident environment that protects residents from abuse including resident to resident abuse of any type. If any staff is made aware of any alleged violation of abuse, neglect, or mistreatment, the facility will thoroughly investigate the alleged violation, attempt to prevent further abuse, neglect, exploitation, and mistreatment from occurring while the investigation is in progress, and take appropriate corrective action because of investigation findings. Any staff member that observed or is informed of any potentially abusive situation is mandated to report this to the registered nurse supervisor on staff. Investigation of the incident will include witness statements, resident statements, and medical evaluations. All attempts will be made by staff to prevent further potential abuse while the investigation is in progress. Resident #282 most recent admission was on 02/11/19. Resident has diagnoses including but not limited to Parkinson's Disease, Schizophrenia, and Depression. The Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] was reviewed and documented the following: resident has moderately impaired cognition with presence of physical behavior occurring daily including rejection of care occurring one to three days. Resident was identified as putting others at significant risk for physical injury. It was documented that resident exhibited short temper and annoyance daily. The MDS 3.0 quarterly assessment dated [DATE] was reviewed and documented the following: resident has moderately impaired cognition with self-injurious behaviors occurring daily. It was documented that resident exhibited short temper and annoyance daily. The Comprehensive Care Plan (CCP) for Resident to Resident Altercation (Last updated 11/01/18) was reviewed. The CCP identified resident at risk for altercations due to cognitive/mental status. Goal was documented with resident being free of altercations in ninety days. Interventions include staff observing during rounds and care (effective 05/11/16), initiate resident to resident altercation protocol (effective 05/11/16), social services will follow up to assess psychosocial well-being following an incident (effective 05/11/16), encourage resident to voice peer concerns to staff (effective 05/11/16), encourage resident to participate in activities of interest (effective 05/11/16), refer to psychiatrist and psychologist as needed (effective 05/11/16), and one to one observation (effective 04/10/18). The CCP for Behavioral Symptoms (Last Updated 02/20/19) was reviewed. The CCP identified resident with physical abusive and aggressive behaviors related to a diagnosis of a mental disorder and dementia and cognitive disorder. Goal was documented that resident will demonstrate fewer episodes of inappropriate behavior and will have improved behavior in ninety days. Interventions include attempt to ascertain reason for behavior (effective 11/10/16), administer medications as per physician orders (effective 04/10/18 and 04/25/18), assess response to medication (effective 04/25/18), maintaining a calm environment (effective 11/10/16 and 04/25/18), psychiatric consult (effective 04/10/18 and 04/25/18), approach in a calm and gentle manner (effective 11/10/16 and 04/25/18), explain procedures to be performed (effective 11/10/16 and 04/25/18), maintain clutter free environment (effective 04/25/18), re-approach as needed (effective 06/12/18), assure resident medical issues will be addressed as they arise (effective 11/10/16), encourage participation in activities of choice (effective 11/10/16), provide a private room (effective 04/10/18), provide one on one observation (effective 04/10/18), diversional activities (effective 04/10/18), identify and meet resident needs (effective 04/10/18). The CCP documented no implementation of new interventions since 04/25/18. Physician orders were reviewed and documented the following orders. Resident was placed on one to one observation from 04/10/18 to 10/23/18. The resident was placed on every thirty-minute checks from 10/4/18 to 10/9/18 and from 02/16/19 to 02/17/19. The resident was also placed on every fifteen-minute observation from 5/20/18 to 6/12/18. Investigation reports were reviewed for the past year from January 2018 to current February 2019. Resident has a history of incidents involving resident to resident altercations with resident as the aggressor. Incidents occurred on 04/10/18 (NY#00218240), 04/29/18 (NY#00227763), 06/19/18 (NY#00227670), and 07/23/18 (NY#00225651). All cases were investigated and closed. Investigation on a resident to resident altercation that occurred on 07/23/18 (NY#00227907) at 01:00 PM was reviewed. Resident #282 was being wheeled in his wheelchair down the hallway to the scale by the Certified Nursing Assistant (CNA) when suddenly resident #282 hit resident #24 in the face who was passing by. Staff quickly intervened and separated residents. Resident #282 was monitored closely. Later, the same day at 02:50 PM, resident #282 attacked another resident #183 (NY#00225651 Closed). Resident #282 was eventually sent out to the hospital on [DATE] for further evaluation of aggressive behaviors. The investigation summary provided did not include staff or witness statements. Nursing, Physician, and Social Work progress notes were reviewed from 04/2018 to current 02/2019. All disciplines documented incidents of resident to resident altercations. Interventions were not reviewed for effectiveness as no new interventions were implemented to prevent further incidents from occurring. Resident nursing instructions documented resident safety with one to one monitoring for safety (effective 10/27/17) and then only every 15-minute monitoring for safety (effective 07/19/18). On 02/21/19 at 11:26 AM and on 02/22/19 at 11:00 AM, the LPN #2 on the third floor was interviewed. Incidents on 04/29/18, 06/19/18, 07/23/18 occurred on third floor. LPN #2 stated resident behaviors include him acting up unexpectedly where resident will make sudden movements and attack others. LPN #2 stated she immediately separates the residents if there's an altercation and reports it to the supervisor. She stated when resident is asked why he hits others he cannot explain due to cognitive impairment. LPN #2 stated the resident was only on every 15-minute monitoring as an intervention and never on a one to one. She further stated resident was not on a one to one because a staff was not assigned on schedule for it. On 02/21/19 at 11:40 AM, the Registered Nurse Supervisor (RNS) #3 who is covering the second and third floor was interviewed. She stated she had just started working a couple of months ago and was not present when the above incidents occurred. She stated if any staff witness any incidents, the CNA will report to charge nurse who will report to the supervisor. Staff are expected to immediately intervene, keep resident safe, call for help, and report to supervisor. Supervisors then report to the Assistant Director of Nursing (ADON) or the Director of Nursing (DON). RNS #3 stated the investigation is started right away by getting statements, complete assessments including physicals, and put a plan in place. Investigations should be completed within 24 to 48 hours. If there is suspicion of abuse, the ADON or DON will report it to the NYSDOH within 24 hours of incident occurring. On 02/22/19 at 10:37 AM, the Licensed Practical Nurse (LPN) #1 on the second floor was interviewed. Incident on 04/10/18 occurred on second floor. LPN #1 stated resident behaviors include being non-compliant with care, throws items on the floor, and becomes physically aggressive with residents and staff. She stated when a resident to resident incident occurs, she immediately separates the residents and places them in their room and notify the supervisor and physician. LPN #1 stated when incidents occurred on her floor, interventions included placing resident on a one to one and resident has been sent to the emergency room for a psychiatric evaluation. Resident was also being monitored every 15 minutes. There were no new interventions aside from those. On 02/21/19 at 03:49 PM and on 02/22/19 at 02:00 PM, the DON was interviewed. She stated when there is an incident, the staff on the unit will intervene right away by separating the residents and making sure they are safe. The staff who witness it reports it to the charge nurse and/or supervisor. The supervisor then reports it to the DON. The investigation is conducted right away. The ADON was responsible for making sure the investigation was completed. DON stated an investigation is comprised of a report of what had happened, staff statements, staff interviews, and resident interviews if possible. It should also include notification of the physician and family. An assessment is also completed to assess for injury. The resident will also be referred to social services and/or psychiatry or other disciplines as needed. The ADON did not complete the investigation and had resigned 10/2018. DON stated it was her responsibility as well to make sure investigations are completed with all the elements included. DON stated resident #282 behavior is spontaneous and unpredictable. Resident #282 was placed on every 15- or 30-minute monitoring. She then stated resident #282 was not always on one to one and was only on it briefly even though the physician orders stated otherwise. DON stated the orders might have automatically renewed every month, but staff was not on schedule to complete the one to one. DON stated the interdisciplinary team which is composed of the administrator, DON, corporate nurse, physical/occupational therapist, recreation, social work, and RNS, review effectiveness of interventions during MDS meetings and as needed. DON stated interventions that were carried out for resident #282 were keeping him away from other residents, monitor him closely, redirecting, changing units, putting him with residents who can defend themselves, and involving family. She further stated these interventions were not all documented and should have been. 415.4(b)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews during the re-certification survey and abbreviated survey (NY#00227907, the facility did not ensure that alleged violations involving abuse, neglect, exploitation or mistreatment were reported to the proper authorities within prescribed time frames. Specifically, an allegation of abuse that occurred in July 2018 was not reported to the NYS DOH until October 2018. This was evident in 1 out of 4 residents reviewed for resident to resident altercation and abuse care area (Resident #282). The finding is: The facility policy and procedure titled, Abuse Prevention (Dated 11/2018) documented the following: Reporting/Response-immediately reporting all alleged violations to the Administrator and to the DNS; Reporting, when necessary, to the police and the NYS DOH within specified timeframes. Resident #282 most recent admission was on 02/11/19. Resident has diagnoses including but not limited to Parkinson's Disease, Schizophrenia, and Depression. The Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] was reviewed and documented the following: Resident has moderately impaired cognition with presence of physical behavior occurring daily including rejection of care occurring one to three days. Resident was identified as putting others at significant risk for physical injury. It was documented that resident exhibited short temper and annoyance daily. The MDS 3.0 quarterly assessment dated [DATE] was reviewed and documented the following: Resident has moderately impaired cognition with self injurious behaviors occurring daily. It was documented that resident exhibited short temper and annoyance daily. Investigation reports were reviewed for the past year from January 2018 to current February 2019. Resident has a history of incidents involving resident to resident altercations with resident as the aggressor. Incidents occurred on 04/10/18 (NY#00218240), 04/29/18 (NY#00227763), 06/19/18 (NY#00227670), and 07/23/18 (NY#00225651). All cases were investigated and closed. Investigation on a resident to resident altercation that occurred on 07/23/18 (NY#00227907) at 01:00 PM was reviewed. Resident #282 was being wheeled in his wheelchair down the hallway to the scale by the Certified Nursing Assistant (CNA) when suddenly resident #282 hit resident #24 in the face who was passing by. Staff quickly intervened and separated residents. Resident #282 was monitored closely. Later on the same day at 02:50 PM, resident #282 attacked another resident #183 (NY#00225651 Closed). Resident #282 was eventually sent out to the hospital on [DATE] for further evaluation of aggressive behaviors. The facility documented there is reasonable cause to believe that abuse, neglect, mistreatment, exploitation or misappropriation has occurred and as a result the NYSDOH was notified. The investigation was completed on 7/27/18, however was not reported to NYSDOH until 10/15/18. On 02/21/19 at 11:40 AM, the Registered Nurse Supervisor (RNS) #3 who is covering the second and third floor was interviewed. She stated she had just started working a couple of months ago and was not present when the above incidents occurred. She stated if any staff witness any incidents, the CNA will report to charge nurse who will report to the supervisor. Staff are expected to immediately intervene, keep resident safe, call for help, and report to supervisor. Supervisors then report to the Assistant Director of Nursing (ADON) or the Director of Nursing (DON). RNS #3 stated the investigation is started right away by getting statements, complete assessments including physicals, and put a plan in place. Investigations should be completed within 24 to 48 hours. If there is suspicion of abuse, the ADON or DON will report it to the NYSDOH within 24 hours of incident occurring. On 02/21/19 at 03:49 PM and on 02/22/19 at 02:00 PM, the DON was interviewed. She stated when there is an incident, the staff on the unit will intervene right away by separating the residents and making sure they are safe. The staff who witness it reports it to the charge nurse and/or supervisor. The supervisor then reports it to the DON. The investigation is conducted right away. The ADON was responsible for making sure the investigation were completed. DON stated an investigation is comprised of a report of what had happened, staff statements, staff interviews, and resident interviews if possible. It should also include notification of the physician and family. An assessment is also completed to assess for injury. The resident will also be referred to social services and/or psychiatry or other disciplines as needed. The ADON did not complete the investigation and had resigned 10/2018. DON stated it was her responsibility as well to make sure investigations are completed with all the elements included. 415.4(b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews during the re-certification survey andand abbreviated survey (NY#00227907, the facility did not take appropriate actions in response to an alleged violation of abuse, neglect, exploitation, or mistreatment. Specifically, the facility did not ensure an investigation involving a resident to resident altercation was thoroughly investigated to include witness statements and to prevent further incidents from occurring. This was evident for 1 of 4 residents reviewed for resident to resident altercation and abuse care area (Resident #282). The finding is. The facility policy and procedure titled, Abuse Prevention (Dated 11/2018) documented the following: The facility policy is to provide a safe resident environment that protects residents from abuse including resident to resident abuse of any type. If any staff is made aware of any alleged violation of abuse, neglect, or mistreatment, the facility will thoroughly investigate the alleged violation, attempt to prevent further abuse, neglect, exploitation, and mistreatment from occurring while the investigation is in progress, and take appropriate corrective action as a result of investigation findings. Any staff member that observed or is informed of any potentially abusive situation is mandated to report this to the registered nurse supervisor on staff. Investigation of the incident will include witness statements, resident statements, and medical evaluations. All attempts will be made by staff to prevent further potential abuse while the investigation is in progress. Resident #282 most recent admission was on 02/11/19. Resident has diagnoses including but not limited to Parkinson's Disease, Schizophrenia, and Depression. The Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] was reviewed and documented the following: resident has moderately impaired cognition with presence of physical behavior occurring daily including rejection of care occurring one to three days. Resident was identified as putting others at significant risk for physical injury. The MDS 3.0 quarterly assessment dated [DATE] was reviewed and documented the resident has moderately impaired cognition with no presence of behaviors. The Comprehensive Care Plan (CCP) for Resident to Resident Altercation (Last updated 11/01/18) was reviewed. The CCP identified resident at risk for altercations due to cognitive/mental status. Goal was documented with resident being free of altercations in ninety days. Interventions include staff observing during rounds and care (effective 05/11/16), initiate resident to resident altercation protocol (effective 05/11/16), social services will follow up to assess psychosocial well being following an incident (effective 05/11/16), encourage resident to voice peer concerns to staff (effective 05/11/16), encourage resident to participate in activities of interest (effective 05/11/16), refer to psychiatrist and psychologist as needed (effective 05/11/16), and one to one observation (effective 04/10/18). The CCP for Behavioral Symptoms (Last Updated 02/20/19) was reviewed. The CCP identified resident with physical abusive and aggressive behaviors related to a diagnosis of a mental disorder and dementia and cognitive disorder. Goal was documented with resident will demonstrate fewer episodes of inappropriate behavior and will have improved behavior in ninety days. Interventions include attempt to ascertain reason for behavior (effective 11/10/16), administer medications as per physician orders (effective 04/10/18 and 04/25/18), assess response to medication (effective 04/25/18), maintaining a calm environment (effective 11/10/16 and 04/25/18), psychiatric consult (effective 04/10/18 and 04/25/18), approach in a calm and gentle manner (effective 11/10/16 and 04/25/18), explain procedures to be performed (effective 11/10/16 and 04/25/18), maintain clutter free environment (effective 04/25/18), re-approach as needed (effective 06/12/18), assure resident medical issues will be addressed as they arise (effective 11/10/16), encourage participation in activities of choice (effective 11/10/16), provide a private room (effective 04/10/18), provide one on one observation (effective 04/10/18), diversional activities (effective 04/10/18), identify and meet resident needs (effective 04/10/18). The CCP reveals no new interventions were implemented since 04/25/18. Physician orders were reviewed and documented the following orders: Resident was placed on one to one observation from 04/10/18 to 10/23/18. The resident was placed on every thirty minute checks from 10/4/18 to 10/9/18 and from 02/16/19 to 02/17/19. In addition, the resident was placed on every fifteen minute observation from 5/20/18 to 6/12/18. Investigation reports were reviewed for the past year from January 2018 to current February 2019. Resident has a history of incidents involving resident to resident altercations with resident as the aggressor. Incidents occurred on 04/10/18 (NY#00218240), 04/29/18 (NY#00227763), 06/19/18 (NY#00227670), and 07/23/18 (NY#00225651). All cases were investigated and closed. Investigation on a resident to resident altercation that occurred on 07/23/18 (NY#00227907) at 01:00 PM was reviewed. Resident #282 was being wheeled in his wheelchair down the hallway to the scale by the Certified Nursing Assistant (CNA) when suddenly resident #282 hit resident #24 in the face who was passing by. Staff quickly intervened and separated residents. Resident #282 was monitored closely. Later on the same day at 02:50 PM, resident #282 attacked another resident #183 (NY#00225651 Closed). Resident #282 was eventually sent out to the hospital on [DATE] for further evaluation of aggressive behaviors. The investigation summary provided did not include staff or witness statements. Nursing, Physician, and Social Work progress notes were reviewed from 04/2018 to current 02/2019. All disciplines documented incidents of resident to resident altercations. Interventions were not reviewed for effectiveness as no new interventions were implemented to prevent further incidents from occurring. Resident nursing instructions documented resident safety with one to one monitoring for safety (effective 10/27/17) and then only every 15 minute monitoring for safety (effective 07/19/18). On 02/21/19 at 11:26 AM and on 02/22/19 at 11:00 AM, the LPN #2 on the third floor was interviewed. Incidents on 04/29/18, 06/19/18, 07/23/18 occurred on third floor. LPN #2 stated resident behaviors include him acting up unexpectedly where resident will make sudden movements and attack others. LPN #2 stated she immediately separates the residents if there's an altercation and reports it to the supervisor. She stated when resident is asked why he hits others he cannot explain due to cognitive impairment. LPN #2 stated the resident was only on every 15 minute monitoring as an intervention and never on a one to one. She further stated resident was not on a one to one because a staff was not assigned on schedule for it. On 02/21/19 at 11:40 AM the Registered Nurse Supervisor (RNS) #3 who is covering the second and third floor was interviewed. She stated she had just started working a couple of months ago and was not present when the above incidents occurred. She stated if any staff witness any incidents, the CNA will report to charge nurse who will report to the supervisor. Staff are expected to immediately intervene, keep resident safe, call for help, and report to supervisor. Supervisors then report to the Assistant Director of Nursing (ADON) or the Director of Nursing (DON). RNS #3 stated the investigation is started right away by getting statements, complete assessments including physicals, and put a plan in place. Investigations should be completed within 24 to 48 hours. If there is suspicion of abuse, the ADON or DON will report it to the NYSDOH within 24 hours of incident occurring. On 02/22/19 at 10:37 AM, the Licensed Practical Nurse (LPN) #1 on the second floor was interviewed. Incident on 04/10/18 occurred on second floor. LPN #1 stated resident behaviors include being non-compliant with care, throws items on the floor, and becomes physically aggressive with residents and staff. She stated when a resident to resident incident occurs, she immediately separates the residents and places them in their room, and notify the supervisor and physician. LPN #1 stated when incidents occurred on her floor, interventions included placing resident on a one to one and resident has been sent to the emergency room for a psychiatric evaluation. Resident was also being monitored every 15 minutes. There were no new interventions aside from those. On 02/21/19 at 03:49 PM and on 02/22/19 at 02:00 PM, the DON #1 was interviewed. She stated when there is an incident, the staff on the unit will intervene right away by separating the residents and making sure they are safe. The staff who witness it reports it to the charge nurse and/or supervisor. The supervisor then reports it to the DON. The investigation is conducted right away. The ADON was responsible for making sure the investigation were completed. DON #1 stated an investigation is comprised of a report of what had happened, staff statements, staff interviews, and resident interviews if possible. It should also include notification of the physician and family. An assessment is also completed to assess for injury. The resident will also be referred to social services and/or psychiatry or other disciplines as needed. The ADON did not complete the investigation and had resigned 10/2018. DON #1 stated it was her responsibility as well to make sure investigations are completed with all the elements included. DON #1 stated resident #282 behavior is spontaneous and unpredictable. Resident #282 was placed on every 15 or 30 minute monitoring. She then stated resident #282 was not always on one to one and was only on it briefly even though the physician orders stated otherwise. DON #1 stated the orders might have automatically renewed every month but staff was not on schedule to complete the one to one. DON #1 stated the interdisciplinary team which is composed of the administrator, DON, corporate nurse, physical/occupational therapist, recreation, social work, and RNS, review effectiveness of interventions during MDS meetings and as needed. DON #1 stated interventions that were carried out for resident #282 were keeping him away from other residents, monitor him closely, redirecting, changing units, putting him with residents who can defend themselves, and involving family. She further stated these interventions were not all documented and should've been. 415.4(b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility did not ensure that the Minimum Data Set (MDS) assessment accurately reflected the resident's status. Specifically, resident's psychiatric diagnosis and the use of psychotropic drugs was not captured on the MDS. This was evident for 1 of 5 residents reviewed for Unnecessary Medications out of a total investigation sample of 56 residents. (Resident #36) The finding is: Resident #36 was admitted to the facility on [DATE] with diagnoses that included Seizure Disorder, Acute Ischemic Heart Disease, and Atrial fibrillation. The Medical Progress Note dated 06/01/2018 documented that resident admitted from the hospital with diagnoses that included Cerebrovascular Accident, Bipolar Disorder, Seizures, and Mood disorder and was prescribed Abilify 20 mg PO daily for Bipolar, Donepezil 10 mg PO for Dementia, Keppra 500 mg PO 2 times daily for Seizure. The Psychiatry Note dated 06/05/2018 documented the resident's narrative is that he has no psychiatric illness and a recommendation was made to lower Abilify to 15 mg PO daily. The Psychiatry Note dated 09/04/2018 documented a recommendation that the resident's Abilify dosage be decreased to 10 mg PO daily. Physician's Monthly Progress note dated 10/18/2018 and 11/14/2018 documented that resident is receiving Abilify 10 mg PO daily for Schizophrenia and Donepezil 10 mg PO for Dementia. Psychiatry Note dated 12/04/2018 documented that resident was seen by psychiatrist and recommendation made to decrease Abilify to 7.5 mg PO daily. Psychiatry Progress note dated 02/12/2019 documented that resident was evaluated by psychiatrist, Abilify was reduced to 5 mg PO daily, Namenda 10 mg PO daily added, and Aricept 10 mg PO daily. Comprehensive Care Plan on Psychotropic Drug Use updated 06/12/2018 documented that resident is receiving psychotropic medication. The Quarterly MDS's completed on 9/2/18 and 11/27/18 documented in Section N0410 that Antipsychotics were received on 7 of 7 days, however Section N0450 documented that Antipsychotics were not received and did not reflect that Gradual Dose Reductions (GDR's) were being done. The facility did not ensure that MDS assessments were completed that accurately reflected the resident's status. On 02/20/2019 at 11:55 AM and 03:08 PM, the MDS Coordinator was interviewed. The MDS Coordinator stated that she has been doing MDS for a long time, has received training on proper documentation and has been in charge of the MDS at the facility for about 7 months. The MDS Coordinator further stated that she reviews the resident's current medication and diagnosis on the physicians' monthly notes and current orders to complete the appropriate sections of the MDS. The MDS Coordinator also stated that it was an oversight to have not coded the use of psychotropic medication accurately. She further stated that based on the residents orders GDR's had been attempted and should have been recorded on the MDS however, this too was an oversight. On 02/21/19 at 01:09 PM, the Director of Nursing Services (DNS) was interviewed and stated that she has not been overseeing the accuracy of the documentation of MDS but the MDS coordinator reports any issues regarding MDS to her. The DNS further stated she is involved minimally to ensure that MDS's are completed and submitted in a timely manner. The DNS further stated that there is a consultant who reviews MDS's on a monthly basis to ensure that all MDS assessments are completed and submitted but does not review the the accuracy of the documentation. 415.11(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during the recertification survey, the facility did not ensure that a Comprehensive Care Plan (CCP) with measurable goals and objectives was developed and implemented to address a resident's medical needs. Specifically, 1) a CCP was not created for a resident with a left hand contracture who had been ordered a hand splint. This was evident for 1 of 2 residents reviewed for position/mobility out of a sample of 56 residents. (Resident #103). 2) a CCP was not developed and implemented for a resident provided with an assistive eating device which was observed not being utilized during meals. (Resident # 131). The findings are: The facility policy Comprehensive Person-Centered Care Plan/Baseline Care Plan dated 01/15/2018 documented: The Comprehensive care plan will be developed within 7 days after the completion of the Comprehensive Assessment (RAI/MDS). The Comprehensive Care Plan will include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Resident #103 was admitted to the facility on [DATE] with diagnoses that included Hypertension, Cerebrovascular Accident Accident (CVA), Non-Alzheimer's Dementia, Hemiplegia, Muscle Weakness, Abnormalities of Gait and Mobility. The Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident with intact cognition, had impairment on one side of both lower and upper extremities, required extensive assistance of 1 person with Activities of Daily Living (ADL's) including transfer, dressing, toilet use, and personal hygiene. Physician's order dated 1/30/2019 documented the following: PROM (Passive Range of Motion) to BLE (bilateral lower extremities) and RUE (right upper extremity) for 8 minutes per session BID (twice daily), AROM (Active Range of Motion) to BLE and RUE for 8 minutes per session BID, Left resting hand splint-remove for hygiene. On 02/13/19 at 04:12 PM, Resident #103 was observed wheeling self on the unit towards the elevator, Resident has a contracture on left hand with no hand splint device in place. On 02/14/19 at 11:59 AM, the resident was observed wheeling self in hallway towards the dining room with no splint device in place. On 02/19/19 at 08:50 AM, resident was observed in bed sleeping. No hand splint noted. On 02/20/19 at 10:30 AM, resident was observed wheeling self in hallway towards the nursing station with no hand splint in place. On 02/20/19 at 12:46 PM, resident was observed in room sitting on his wheel chair, and was interviewed about the splint device for his left hand. The resident stated yeah, yeah, yeah, opened the top drawer of the cabinet, took out the blue hand splint and handed it to CNA for assistance putting it on. There was no documented evidence that a CCP had been created to address the resident's contracture or use of splint device as ordered by the physician. On 02/20/19 at 11:18 AM, an interview was conducted with the Certified Nursing Assistant (CNA #1). CNA #1 stated that he started working in the facility in January this year, and has been assisting the resident with care for about a month. CNA #1 also stated that resident is assisted in showering and in dressing as needed, but is able to shave himself with supervision and able to move around in the room and within the facility. CNA#1 further stated that resident has contracture of the left hand but is able to move it with some assistance, and is assisted to perform the range of motion on the left hand as tolerated every shift. CNA#1 also stated that resident has a splint to the left hand but does not know where the resident placed it because resident likes to put it on by himself. On 02/20/19 at 12:56 PM, an interview was conducted with the Licensed Practical Nurse (LPN #1). LPN stated that the resident has order for splint on the left hand and that the staff always assist and encourage the resident to put it on everyday. The resident has a habit of taking it off to put on his jacket, but is always re-directed, encouraged and assisted to put it on constantly. On 02/19 at 09:46 AM, an interview was conducted with the Licensed Practical Nurse (LPN #1). LPN #1 stated that it is the RN supervisor that is responsible for the initiation of the resident's care plan, and that she is only responsible for updating the nursing care plan as needed, monitoring the resident and documenting in the 24-hour report. LPN #1 also stated that if there is a new order for any device, Physical Therapy (PT) or Occupational Therapy (OT) will initiate the care plan. If that is not done, the RN manager will check and initiate the care plan. The LPN also stated that the unit RN supervisor responsible for creating the careplans has been out sick for about 3 weeks. On 02/22/19 at 10:35 AM, Director of Rehab (DOR) was interviewed. DOR stated that when a resident is evaluated and is determined to need an assistive device, it is procured from the supplier, an order is put in and the device delivered to the unit and staff is educated on how to place the device. DOR also stated that the OT or PT that recommends the device initiates the care plan. The resident is monitored and the care plan is updated usually every 90 days or as may be needed. DOR further stated that the splint device was initially recommended and ordered for the resident on 5/16/18 but was not care planned at that time. He stated that resident is supposed to be monitored for tolerance and the care plan update documented every 3 month, but this was missed and an update to the care plan would be made immediately. 02/22/19 at 10:57 AM, the Director of Nursing Services (DNS) was interviewed. DNS stated that if the new device is recommended and ordered, nursing department will be notified by OT or PT. The order will be picked up by the nursing and care plan initiated by the therapist and/or the nurse manager. DNS stated that the affected nurse manager has been out sick. 2. The Nursing policy and procedure titled Special Device dated 7/22/14 documented that residents will be evaluated for assistive devices upon admission, quarterly, annually and as needed. The policy and procedure titled Feeding Assistive Devices dated 7/2014 documented that feeding assistive devices are provided to residents who will benefit from them. This will aid the resident in being more independent in feeding himself/herself. Resident # 131 was admitted on [DATE] with diagnoses of Non-Alzheimer's Dementia, Parkinson's Disease, Depression, and Open-Angle Glaucoma. On 02/14/19 at 12:21 PM, Licensed Practical Nurse (LPN # 2) was observed feeding Resident # 131 with a regular spoon, not with the weighted/bent spoon that was provided on the tray. On 02/20/19 at 12:20 PM, Resident # 131 was observed in the dining room. Placed on the lunch meal tray was a weighted spoon and pureed foods were provided on a one-sided high rim plate. The Certified Nurse Aide (CNA) encouraged the resident to use the weighted spoon. The Resident scooped the food at least three times (3 x) using the weighted spoon and stopped. The CNA who was assisting her with feeding took the regular spoon and began to feed the resident. The Physician's Order dated 11/27/18 documented divided high side dish and weighted spoon during all meals. The February 2019 Resident CNA Documentation Record plus Nursing Instructions did not document the use of the assistive device under the ADL eating. The Occupational Therapy form titled Feeding and Adaptive Equipment dated February 2019 documented that Resident #131 uses a high-sided dish and weighted spoon. The Minimum Data Set (MDS) dated [DATE] documented that Resident #131's hearing was adequate, speech was clear, can make herself understood and was able to understand others. Her vision is moderately impaired. Cognition is severely impaired. Mood symptoms were present on several days including feeling down, depressed or hopeless, feeling tired or having little energy, poor appetite or overeating, and trouble concentrating on things. There was no behavior documented. ADLs documented total dependence with 1 person assist for eating. There were no Speech Language Pathologist SLP), Occupational Therapist (OT), Physical Therapist (PT) treatments documented. There was no restorative Nursing Program for eating and/or swallowing. The Comprehensive Care Plan (CCP) on Assistive Device last updated by Rehabilitation on 1/31/19 documented that the CCP Status was incomplete. The CCP on ADLs/Eating effective 9/22/16 documented the following: Goals: ADL needs will be adequately met by Staff daily. Resident will continue to function at current level daily. She will show improvement in at least 1-2 ADL function. Interventions: Assist with needs; encourage maximum action participation in ADL; monitor changes in functional status and refer to PT/OT if needed. Offer/provide protective dining apron at mealtime. The Resident's lunch meal ticket dated Wednesday, 2/20/19 documented No Concentrated Sweets (NCS), Puree diet, Bent spoon, high side dish. On 02/20/19 at 10:37 AM, Certified Nursing Assistant (CNA) #4 was interviewed. CNA #4 stated that she helps Resident #131 during feeding. She needs help during feeding; she can feed herself but it's hard for her. She has a weighted spoon, but I think it's heavy for her. On 02/20/19 at 02:31 PM, CNA #4 was re-interviewed. CNA stated that she knows the purpose of the assistive eating device- the weighted spoon because there was another Resident who had the fat-handled spoon. At one time, she heard a Physical Therapist (PT) talking to the resident who was having difficulty gripping the regular spoon, asking if the resident preferred the fat-handled spoon. The one-sided high rim plate is used so she could slide and scoop her food to feed herself. She stated that she never got any in-service on the use of the assistive eating device. On 02/20/19 at 12:41 PM, LPN #2 was interviewed and stated the weighted spoon is used to encourage the resident to eat with some independence. The plate edge will help her to spoon the food. If she wants to, she will use the spoon. On 02/20/19 at 12:56 PM, Director of Rehab (DOR) was interviewed. The DOR stated there is an order for the weighted spoon and high side dish and both items should be used for all meals. The resident is re-evaluated for continued use on a quarterly basis. The DOR also stated that when device is first provided to the resident the Rehab department would provide in-service on how the device is to be used. The DOR could not locate a CCP for the assistive device. 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during the recertification survey, the facility did not ensure that treatment and care to address the resident's range of motion needs were provided in accordance with professional standards of practice. Specifically, splint devices for a resident's left hand contracture were not applied as ordered by the physician and a Comprehensive Care Plan (CCP) was not created for range of motion or splint device use. This was evident for 1 of 2 residents reviewed for position/mobility out of a sample of 56 residents. (Resident #103). The findings are: The facility policy Comprehensive Person-Centered Care Plan/Baseline Care Plan dated 01/15/2018 documented: The Comprehensive care plan will be developed within 7 days after the completion of the Comprehensive Assessment (RAI/MDS). The Comprehensive Care Plan will include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Resident #103 was admitted to the facility on [DATE] with diagnoses that included Hypertension, Cerebrovascular Accident Accident (CVA), Non-Alzheimer's Dementia, Hemiplegia, Muscle Weakness, Abnormalities of Gait and Mobility. The Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident with intact cognition, had impairment on one side of both lower and upper extremities, required extensive assistance of 1 person with Activities of Daily Living (ADL's) including transfer, dressing, toilet use, and personal hygiene. Physician's order dated 1/30/2019 documented the following: PROM (Passive Range of Motion) to BLE (bilateral lower extremities) and RUE (right upper extremity) for 8 minutes per session BID (twice daily), AROM (Active Range of Motion) to BLE and RUE for 8 minutes per session BID, Left resting hand splint-remove for hygiene. On 02/13/19 at 04:12 PM, Resident #103 was observed wheeling self on the unit towards the elevator, Resident has a contracture on left hand with no hand splint device in place. On 02/14/19 at 11:59 AM, the resident was observed wheeling self in hallway towards the dining room with no splint device in place. On 02/19/19 at 08:50 AM, resident was observed in bed sleeping. No hand splint noted. On 02/20/19 at 10:30 AM, resident was observed wheeling self in hallway towards the nursing station with no hand splint in place. On 02/20/19 at 12:46 PM, resident was observed in room sitting on his wheel chair, and was interviewed about the splint device for his left hand. The resident stated yeah, yeah, yeah, opened the top drawer of the cabinet, took out the blue hand splint and handed it to CNA for assistance putting it on. The hand splint device was not applied as ordered by the physician and there was no documented evidence that the resident was monitored for the appropriate use of the device. There was no documented evidence that a CCP had been created to address the resident's contracture or use of splint device as ordered by the physician. On 02/20/19 at 11:18 AM, an interview was conducted with the Certified Nursing Assistant (CNA #1). CNA #1 stated that he started working in the facility in January this year, and has been assisting the resident with care for about a month. CNA #1 also stated that resident is assisted in showering and in dressing as needed, but is able to shave himself with supervision and able to move around in the room and within the facility. CNA#1 further stated that resident has contracture of the left hand but is able to move it with some assistance, and is assisted to perform the range of motion on the left hand as tolerated every shift. CNA#1 also stated that resident has a splint to the left hand but does not know where the resident placed it because resident likes to put it on by himself. On 02/20/19 at 12:56 PM, an interview was conducted with the Licensed Practical Nurse (LPN #1). LPN stated that the resident has order for splint on the left hand and that the staff always assist and encourage the resident to put it on everyday. The resident has a habit of taking it off to put on his jacket, but is always re-directed, encouraged and assisted to put it on constantly. On 02/19 at 09:46 AM, an interview was conducted with the Licensed Practical Nurse (LPN #1). LPN #1 stated that it is the RN supervisor that is responsible for the initiation of the resident's care plan, and that she is only responsible for updating the nursing care plan as needed, monitoring the resident and documenting in the 24-hour report. LPN #1 also stated that if there is a new order for any device, Physical Therapy (PT) or Occupational Therapy (OT) will initiate the care plan. If that is not done, the RN manager will check and initiate the care plan. The LPN also stated that the unit RN supervisor responsible for creating the careplans has been out sick for about 3 weeks. On 02/22/19 at 10:35 AM, Director of Rehab (DOR) was interviewed. DOR stated that when a resident is evaluated and is determined to need an assistive device, it is procured from the supplier, an order is put in and the device delivered to the unit and staff is educated on how to place the device. DOR also stated that the OT or PT that recommends the device initiates the care plan. The resident is monitored and the care plan is updated usually every 90 days or as may be needed. DOR further stated that the splint device was initially recommended and ordered for the resident on 5/16/18 but was not care planned at that time. He stated that resident is supposed to be monitored for tolerance and the care plan update documented every 3 month, but this was missed and an update to the care plan would be made immediately. 02/22/19 at 10:57 AM, the Director of Nursing Services (DNS) was interviewed. DNS stated that if the new device is recommended and ordered, nursing department will be notified by OT or PT. The order will be picked up by the nursing and care plan initiated by the therapist and/or the nurse manager. DNS stated that the affected nurse manager has been out sick. 415.12

Based on observations, record reviews and interviews, the facility did not ensure that the residents rights to a dignified existence and treat each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. Specifically, Nursing staff were standing over residents while assisting them to eat. This is evident for 9 out of 56 residents observed during the dining task of the recertification survey (Resident #s 9, 41, 46, 55, 115, 130, 131, 175, 180.) The findings are: On 02/13/19 at 12:31 PM, Certified Nurse Aide/s(CNA/s) fed three residents by standing next to them instead of seated in front of them. (Resident # 46 by CNA #6, Resident # 130 by CNA#7, and Resident #180 by CNA #3). A Licensed Practical Nurse (LPN #2) took over feeding a resident (Resident #4). LPN#2 also fed the resident while standing next to the resident. On 02/14/19 at 12:17 PM, LPN #2 was feeding Resident #131 while standing next to the resident. LPN #2 then fed another resident (Resident #115). LPN #2 also fed the resident while standing. On 02/14/19 at 12:22 PM to 12:31 PM, four CNAs were observed feeding four residents while standing next to them. (Resident #46 by CNA #8, Resident #130 by CNA #7, Resident #55 by CNA #9 and Resident #180 by CNA#3.) CNA#10 was observed sitting down in the beginning of the meal while feeding the resident. CNA #10 then stood up and began feeding Resident #41. On 02/14/19 at 12:38 PM, in the Small Dining Room (SDR), two residents were fed by 2 CNAs standing next to them (Resident #9 by CNA#11 and Resident #175 was fed by CNA #12). The facility policy and procedure titled Meal Pass and dated 2/20/19 documented on procedure #16 that residents who need to be fed should be fed immediately after the tray is placed before him/her. All persons feeding residents should be seated. On 02/20/19 at 10:37 AM, CNA #4 was interviewed. CNA helps out feeding a resident. This resident can feed herself but it's hard to feed herself, so she needs to be fed. She has a weighted spoon, but I think it's heavy for her. On a later interview (02/20/19 at 02:31 PM), she stated that staff should be sitting next to the resident during feeding; but there are only 2-fold up green chairs that are used for feeding. If another staff is using them, I cannot use it. These 2 chairs are used for both the main DR and the small dining rooms. Everybody is aware including LPN#2 but not RN#3 and RN #4 may not know about the green chairs. The former Floor Manager knows about the green chairs. On 02/20/19 at 02:47 PM, CNA#5 was interviewed. CNA #5 stated she is responsible for feeding 3 other residents. CNA#5 said she is supposed to be sitting down but we don't have anything to sit on. They have these collapsible chairs which are too low for her since she is tall. The CNA's have only 2 collapsible, green chairs which are used in the main dining room. They had stools which had wheels but residents sit on them, and one resident who sat on it almost fell on the floor, so they were taken away. On 02/20/19 at 03:10 PM, LPN#2 was interviewed. LPN#2 stated that staff stands next to the resident while feeding them. There is no issue feeding the resident standing up. She stated that she doesn't know if it is the proper way. She stated, I usually feed them standing up. On 02/20/19 at 03:52 PM, RN#3 was interviewed. RN#3 stated that the CNA's are not supposed to be standing next to the residents while feeding them; they should be sitting. They are supposed to have eye contact with the resident and not towering over them. Staff needs to be engaging the residents. There was no in-service training provided to staff on feeding the residents. On 02/22/19 at 09:09 AM, CNA # 3 was interviewed. CNA#3 stated that if there's a chair she will be sitting next to the resident while feeding. Chairs came up yesterday. Sometimes, it is comfortable sitting to feed them because they take a long time to eat. She stated that it's better for the resident because you are in the same eye level as the resident. Feeding residents while sitting next to them encourages them to eat more because they see you at an eye level. On 02/22/19 at 09:19 AM, CNA #6 was interviewed. CNA stated that LPN #2 trained her how to feed a resident. CNA#6 stated that she just finished training at an institute last September. She learned that the State regulation states that she needs to sit next to the resident while feeding because it will be less intimidating, they see you at eye level, they could see who was feeding them and interact with them. CNA said she was standing next to the residents while feeding them last week. There might not be a chair due to space in between the two residents. 415.3(c)(1)(i)

Based on resident and staff interviews and record reviews during the re-certification survey, the facility did not ensure resident rights were maintained. Specifically, residents did not receive their mail including letters, packages, and other materials in a timely manner. This was evident in fourteen (14) of 14 residents (#20, 38, 162, 8, 6, 65, 154, 39, 2, 35, 68, 179, 57, 148) who attended the Resident Council meeting. The finding is: The facility policy and procedure titled, Privacy and Confidentiality (Dated 11/2017) was reviewed.Mail is delivered to residents within 24 hours of receiving it on regularly scheduled days . On 02/14/19 from 11:00 AM to 11:30 AM, a Resident Council meeting was held with 14 residents. All 14 of 14 residents reported mail is not always delivered stating staff would say mail will be delivered whenever they get around to it. Residents also stated they receive mail up to 3 weeks late. They know this because they see when the letter is postmarked. All residents further stated they do not sign off on anything when they receive mail and there's no set scheduled for when they receive mail. They also stated they do not receive mail on the weekend including Saturdays. On 02/22/19 at 09:31 AM, the Director of Recreation was interviewed. She stated mail is delivered to the facility where Book Keeping/Finance sorts it. All resident mail is then given to recreation to sort resident's mail per floor and assigned to staff members for daily distribution, Monday through Friday. It is normally distributed towards the end of the day otherwise it will be handed out the next day. Mail is not distributed over the weekend, including Saturday because Book Keeping/Finance is not here. Weekend mail is not taken care of until Monday. The Director of Recreation further stated she does not keep track of mail being delivered to the residents, specifically, which resident received mail and when it was delivered. On 02/22/19 09:41 AM, the Book Keeper was interviewed. She stated mail is delivered to the facility where she sorts it. All resident letters go to recreation for distribution. The book keeper stated the mail comes late so sometimes it gets sorted the same day or the next. She further stated mail is not handled over the weekend, including Saturdays due to nobody working. The weekend mail gets sorted on Monday. The book keeper then stated she does not keep a log or tracking documentation to show they received and handed out mail. 415.3(d)(2)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) During multiple observations made between 02/13/19 03:10 PM and 02/19/19 12:21 PM, many housekeeping and maintenance issues were found. In Resident room [ROOM NUMBER]-worn, chipped head board. Wall dirty with brownish marks next to bed. Bathroom doors in disrepair, chipped with splinters. Paper holder ajar. In Resident room [ROOM NUMBER]-stained ceiling tile, dusty window ledges, bathroom door with mismatched patches, outer base of tub discolored, peeling paint, radiator in bathroom dusty, wall tiles in bathroom dusty and dirty, and unpainted wall next to sink, closet drawers off tracks. In Resident room [ROOM NUMBER]- outer base of bath tub discolored with chipped peeling paint. In Resident room [ROOM NUMBER]-dust over wall socket and wire housing, dusty window ledges, brownish spills on wall under socket, multiple unsightly patches on bolted bathroom door, different colored patches of paint on bedroom wall, and rusted window blinds. In Resident room [ROOM NUMBER]-lower base of tub discolored, soiled towel on top of covered tub, bathroom door with multiple patches, chipped dressers, bathroom door frame rotted at lower left corner. In Resident room [ROOM NUMBER]- radiator cover loose in corner. Dusty window ledges. Room door with chipped, separating plywood. The Bathroom doors were in disrepair, both patched in several places, and mismatched wall paint in several areas in bedroom. In Resident room [ROOM NUMBER] there was mismatched paint on walls, dusty window ledges, dust and dirt on wiring housing. In the men's bathroom next to room [ROOM NUMBER] there was a heavy urine odor, mismatched paint on wall above 1st sink. In the last toilet stall there was a heavy urine odor, dried brown stains on edges of stall floor, stall walls were soiled with whitish substances in several places. There was mismatched paint on stall walls, stained ceiling tiles, rust at base of dividing stall walls, and ground in brown stains on floor tiles. The privacy curtains were soiled with brownish black marks, hanging askew from curtain rod. The men's bathroom next to room [ROOM NUMBER] there were soiled wall tiles. There were curtain hooks above the door with no curtain hanging. A patched, unpainted area on bathroom wall. In adjacent bathroom two badly worn mirrors, dusty, dirty radiator cover. There were whitish splashes on stall walls and tiles and ground in brown stains on floor tiles. In room [ROOM NUMBER] there was a strong urine odor that could be smelled from the hallway. There were orange colored stains underneath bed B. There was mismatched wall paint in corridors past room [ROOM NUMBER]. In multiple rooms the corners and floors needed sweeping and mopping. Table edges at the 2nd floor nursing station noted with chipped edges. Resident's charts on the table at the nursing station with brownish stains. On 02/21/19 at 03:05 PM and on 2/22/19 at 10:09 AM, interviews were held with the Housekeeping/Maintenance Director. He stated he does a minimum of weekly rounds and as often as possible. This includes all resident rooms being checked for cleanliness and broken or missing furniture on the unit where the unit is picked randomly. A checklist is used to indicate what was checked in each resident room. A check mark is satisfactory, and an X mark is unsatisfactory. He stated that he has a check list too which includes the dusting of the windows. There is a schedule of the staff's daily assignments. This schedule instructs the staff on what needs to be done daily. The schedule is posted on the bulletin board in porter's room. He stated that he has as a log, which he uses to check that the work is done as scheduled. If any staff is lacking on the assignment, he or she is instructed to re-do it. Some resident rooms are difficult to maintain, but efforts are made to ensure every room is kept clean and tidy. The Maintenance Director stated that the facility had a staff member assigned to strip and mop the floor, but recently lost him. The facility is in the process of hiring someone to take over that task. As for the overbed tables that are in disrepair, the director stated that the facility has purchased a new set of tables to replace all the rusted overbed tables. He further stated that the facility is in the process of fixing and replacing the damaged and missing drawers. The maintenance director stated that rooms noted with strong urine odor are always given special treatment, staff are instructed to pay special attention to all the affected rooms. The director stated that the facility also just hired a plumber to fix all the damaged and leaking pipes and tiles. The maintenance communication book for the second floor was reviewed. The book was checked off daily by maintenance staff. However, there was not consistent documentation noting the reporting of maintenance or housekeeping issues. It also did not document any observations or reporting of faulty equipment. 415.5(h)(2) Based on observations, record review, and staff interviews during the re-certification survey, the facility did not ensure housekeeping and maintenance services were provided to maintain a sanitary, orderly, and comfortable interior. Specifically including but not limited to, resident furniture was observed to be in disrepair. This was evident on 2 of 3 resident care units. (Units 2 and 3.) The finding is. 1) On 02/14/19 at 02:30 PM and on 02/21/19 at 09:13 AM, Resident #180 room on floor 3 North was observed with a missing drawer from its wardrobe closet. 2) On 02/21/19 at 08:45 AM, Surveyor observed in the room of Resident #157, a rectangular white patch below the window. It was a different paint color from the paint in the rest of the room. The floor 3 North Maintenance Book was reviewed from 1/2018 to Current. There was no documentation regarding above resident closet drawer missing. Almost 99% documentation in the book is documented as Checked by (initial of worker). On 02/21/19 at 09:14 AM, the Certified Nursing Assistant (CNA #3) who cares for resident #180 stated she had reported the missing drawer to maintenance awhile ago verbally only. She further stated there's a maintenance book but staff does not document in it. It's only for maintenance to document that they completed a job that needed to be done that was reported to them verbally.

Based on observations, record review and staff interviews, the facility did not ensure that food is prepared, cooked or stored under appropriate temperatures and with safe handling techniques. Specifically, 1) Foods were not being held at appropriate temperatures to prevent food borne illness.Danger zone temperatures which are between 41F and 135F. 2) the Food Service Staff did not wear beard restraints to prevent hair from contacting food. This was evident during the Kitchen task of the recertification survey. The findings are: 1) On 02/13/19 at 09:21 AM Supervisor #1 and the SA did an initial tour of the kitchen. The refrigerator temperature where juice, lactose milk, sandwiches, jello, applesauce, pudding dated, labeled and stored registered at 38F. On 02/19/19 at 08:40 AM, A follow-up tour of the kitchen was done. The refrigerator temperature where the sandwiches were stored registered at 39F. 02/19/19 11:46 AM [NAME] #1 took the trayline temperature. The following temperatures were read; Cheese sandwich = 62F; Cream Cheese and jelly sandwich = 62F. On 02/19/19 at 12:10 PM Dietary Aide #1 was interviewed. She stated that she has been doing the sandwiches for 1 year. Cheese sandwich was done at 8am. She takes the cheese out of the refrigerator first. She prepares the sandwich by the sandwich area. She prepared 8 cheese sandwiches on whole wheat bread and 8 cheese on white bread. Then she puts the sandwiches in the refrigerator right away. Sandwiches should be 34 - 40F once they are made. If the sandwich temperature is too high, like 50F, because of the sandwich will have bacteria and anybody who eats it could get sick. Cream cheese and jelly sandwich were done 9: 30am. She said she made about 10 cream cheese and jelly on whole wheat bread and 10 cream cheese and jelly on white bread. Bread was stored all the way in the back of the kitchen not in the refrigerator. No temperatures were taken before the sandwiches were made. No temperatures taken before and after the sandwiches at all. On 02/19/19 at12:18 PM DFS was interviewed. In-service training is done quarterly for food temperatures, monthly for hand washing and maintaining the area clean, wearing of appropriate attire. SA request for in-service training sign in sheets, policy and procedure for food temperature. On 02/19/19 12:42 PM 2nd floor 3S, the last of the 3 food trucks left in the kitchen; food was distributed. On 02/19/19 at 12:46 PM test tray done by DFS (Directo of Food Service). Chopped burger = 100F; rice =118F; soup =130F; milk= 58F; cheese sandwich= 62F; pears= 58F; collard greens=120F; Chopped chicken=100F. On 02/19/19 at 02:23 PM at [NAME] #2 was interviewed. He stated that he makes salads. The cold foods should have a temperature of 25-35F. Cold meal should not be closed to warm. He makes sure that when cold items are served for any meal, he makes sure that the steam table has a lot of ice so bacteria will not multiply. You can get sick; diarrhea, vomiting, upset stomach and they end up on a clear liquid diet. In-service training on cold service twice a month, and these in-services were documented. Temperature log sheets are done for hot and cold foods as well served on the trayleind. He doesn't deal with sandwiches, only the cold foods on the trayline. On 02/21/19 at 09:47 AM, Food Service Supervisor(FSS) was interviewed. There is no temp logbook for the sandwiches. Cold sandwiches should be below 32F. Hot food should be 165F and up. Test tray is a sample of what is serving at meals on the unit. The test tray is done once a week but we don't log it. She will inform the kitchen and will tell the kitchen and will come back down. The test tray is taken approx at 12pm on the 1st floor dining. Lunch on the first floor is approximately 12:00 PM. When all the meal trucks come out of the dining room, that's when I take the test tray temperature. There were no policies and procedures for testing food temperatures. 2) The facility policy and procedure titled Hairnets and [NAME] Guards dated 11/15/18 documented that hairnets and beard guards are to be worn at all times while performing any work in the kitchen, this includes outside Staff and any other personnel entering the kitchen. On 02/19/19 at 08:40, [NAME] #1 was cutting peppers. Facial hair was visible and he was not wearing a beard net. The DFS had a visible beard and was not wearing a beard net. On 02/19/19 at 09:07 AM, DFS was interviewed. DFS stated that anyone who has a beard that is loose must wear beard nets. All employees must wear hair nets. Male staff must wear a beard net once in the kitchen. Staff delivering foods on the floor do not need to wear beard nets. DFS stated he must wear a beard net once in the kitchen. On 02/19/19 at 02:23 PM, [NAME] #2 was interviewed. [NAME] #2 stated that it is mandatory especially for the cooks to wear a hairnet, beard nets, clean hands and gloves. [NAME] #2 has a visible beard and said he has to wear a beard net. They must wear hair nets so the hair particles don't fall into foods. In-service training on hair nets and beard guards are done about three times a month. 02/22/19 12:33 PM, [NAME] #1 was interviewed. [NAME] #1 stated that facial hair net must be worn since hair might fall into the food and contaminate the food. Hair might carry bacteria from the street while walking. If the hair falls off, we must throw the food because it is contaminated with germs. 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during the recertification survey, the facility did not ensure that the residents received care in a safe, clean, comfortable and homelike environment. Specifically, the facility did not ensure that a safe, functional, sanitary, and comfortable environment is provided for residents, staff and the public. This was evidenced by multiple observations of the residents' rooms, bathrooms, and nursing station. Findings are: The facility policy and procedure titled Policy & Procedure on Environmental Rounds/Houskeeping dated 12/2017, documented that: It is the policy of Park Nursing Home to provide a safe, clean, comfortable and homelike environment for all residents. During multiple observations made between 02/13/19 03:10 PM and 02/19/19 12:21 PM, the following was observed on the second floor: room [ROOM NUMBER] - worn, chipped head board. Wall dirty with brownish marks next to bed. Bathroom doors in disrepair, chipped with splinters. Paper holder ajar. room [ROOM NUMBER] 5 - stained ceiling tile, dusty window ledges, bathroom door with mismatched patches, outer base of tub discolored, peeling paint, radiator in bathroom dusty, wall tiles in bathroom dusty and dirty, unpainted wall next to sink, closet drawers off tracks. room [ROOM NUMBER] - outer base of bath tub discolored with chipped peeling paint; room [ROOM NUMBER] - dust over wall socket and wire housing, dusty window ledges, brownish spills on wall under socket, multiple unsightly patches on bolted bathroom door, different colored patches of paint on bedroom wall, rusted window blinds; room [ROOM NUMBER] - lower base of tub discolored, soiled towel on top of covered tub, bathroom door with multiple patches, chipped dressers, bathroom door frame rotted at lower left corner; room [ROOM NUMBER]- radiator cover loose in corner. Dusty window ledges. Room door with chipped, separating plywood. Bathroom doors in disrepair-both patched in several places, mismatched wall paint in several areas in bedroom; room [ROOM NUMBER] - mismatched paint on walls, dusty window ledges, dust and dirt on wiring housing; Men's bathroom next to room [ROOM NUMBER]-unoccupied, heavy urine odor, mismatched paint on wall above 1st sink, last toilet stall heavy urine odor, dried brown stains on edges of stall floor, stall walls soiled with whitish substances in several places, mismatched paint on stall walls, stained ceiling tiles, rust at base of dividing stall walls, ground in brown stains on floor tiles, curtains soiled with brownish black marks, hanging askew from curtain rod. Men's bathroom next to room [ROOM NUMBER]-soiled wall tiles, curtain hooks above door-no curtain hanging, patched, unpainted area on bathroom wall. In adjacent bathroom [ROOM NUMBER] badly worn mirrors, dusty, dirty radiator cover, whitish splashes on stall walls and tiles, ground in brown stains on floor tiles. room [ROOM NUMBER] - strong urine odor from hallway, orange colored stains underneath bed B. Mismatched wall paint in corridors past room [ROOM NUMBER]. The table top with chipped edges on second floor nursing station. There were resident's charts on the table at the nursing station stained with brownish dirt On 02/21/19 at 03:05 PM and on 2/22/19 at 10:09 AM interviews were held with the Housekeeping/Maintenance Director. He stated he does a minimum of weekly rounds and as often as possible. This includes all resident rooms being checked for cleanliness and broken or missing furniture on the unit where the unit is picked randomly. A checklist is used to indicate what was checked in each resident room. A check mark is satisfactory, and an X mark is unsatisfactory. He stated that he has a check list to which includes the dusting of the windows. There is a schedule of the staff's daily assignments. This schedule instructs the staff on what needs to be done daily. The schedule is posted on the bulletin board in porter's room. He stated that he has as a log, which he uses to check that the work is done as scheduled. If any staff is lacking on the assignment, he or she is instructed to re-do it. Some resident rooms are difficult to maintain, but efforts are made to ensure every room is kept clean and tidy. The Maintenance Director stated that the facility had a staff member assigned to strip and mop the floor, but recently lost him. The facility is in the process of hiring someone to take over that task. As for the overbed tables that are in disrepair, the director stated that the facility has purchased a new set of tables to replace all the rusted overbed tables. He further stated that the facility is in the process of fixing and replacing the damaged and missing drawers. The maintenance director stated that rooms noted with strong urine odor are always given special treatment, staff are instructed to pay special attention to all the affected rooms. The director stated that the facility also just hired a plumber to fix all the damaged and leaking pipes and tiles. The maintenance communication book for the second floor was reviewed. The book was checked off daily by maintenance staff. However, there was not consistent documentation noting the reporting of maintenance or housekeeping issues. It also did not document any observations or reporting of faulty equipment. 415.29